<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="{$row.presentation_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Characterisation_of_drug_role')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-characterisation_of_drug_role" class="form-control selectpicker" name="row[characterisation_of_drug_role]">
                {foreach name="characterisationOfDrugRoleList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.characterisation_of_drug_role"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Mpid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-mpid_version_date_number"  data-rule="required" class="form-control form-control" name="row[mpid_version_date_number]" type="text" value="{$row.mpid_version_date_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicinal_product_identifier_mpid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicinal_product_identifier_mpid" class="form-control form-control" name="row[medicinal_product_identifier_mpid]" type="text" value="{$row.medicinal_product_identifier_mpid}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Phpid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-phpid_version_date_number" class="form-control form-control" name="row[phpid_version_date_number]" type="text" value="{$row.phpid_version_date_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pharmaceutical_product_identifier_phpid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pharmaceutical_product_identifier_phpid" class="form-control form-control" name="row[pharmaceutical_product_identifier_phpid]" type="text" value="{$row.pharmaceutical_product_identifier_phpid}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicinal_product_name_as_reported_by_the_primary_source')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicinal_product_name_as_reported_by_the_primary_source" class="form-control form-control" name="row[medicinal_product_name_as_reported_by_the_primary_source]" type="text" value="{$row.medicinal_product_name_as_reported_by_the_primary_source}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Identification_of_the_country_where_the_drug_was_obtained')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-identification_of_the_country_where_the_drug_was_obtained" class="form-control form-control" name="row[identification_of_the_country_where_the_drug_was_obtained]" type="text" value="{$row.identification_of_the_country_where_the_drug_was_obtained}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Investigational_product_blinded')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-investigational_product_blinded" class="form-control form-control" name="row[investigational_product_blinded]" type="text" value="{$row.investigational_product_blinded}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Authorisation_application_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-authorisation_application_number" class="form-control form-control" name="row[authorisation_application_number]" type="number" value="{$row.authorisation_application_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Country_of_authorisation_application')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-country_of_authorisation_application" data-source="countrycode/index" data-field="name_cn" class="form-control selectpage form-control" name="row[country_of_authorisation_application]" type="text" value="{$row.country_of_authorisation_application}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name_of_holder_applicant')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name_of_holder_applicant" class="form-control form-control" name="row[name_of_holder_applicant]" type="text" value="{$row.name_of_holder_applicant}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Cumulative_dose_to_first_reaction_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-cumulative_dose_to_first_reaction_number" class="form-control form-control" name="row[cumulative_dose_to_first_reaction_number]" type="text" value="{$row.cumulative_dose_to_first_reaction_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Cumulative_dose_to_first_reaction_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-cumulative_dose_to_first_reaction_unit" class="form-control form-control" name="row[cumulative_dose_to_first_reaction_unit]" type="text" value="{$row.cumulative_dose_to_first_reaction_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gestation_period_at_time_of_exposure_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gestation_period_at_time_of_exposure_number" class="form-control form-control" name="row[gestation_period_at_time_of_exposure_number]"
                   type="number" value="{$row.gestation_period_at_time_of_exposure_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gestation_period_at_time_of_exposure_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gestation_period_at_time_of_exposure_unit" class="form-control form-control" name="row[gestation_period_at_time_of_exposure_unit]" type="text" value="{$row.gestation_period_at_time_of_exposure_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Actions_taken_with_drug')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-actions_taken_with_drug" class="form-control selectpicker" name="row[actions_taken_with_drug]">
                {foreach name="actionsTakenWithDrugList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.actions_taken_with_drug"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Additional_information_on_drug_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-additional_information_on_drug_free_text" class="form-control  form-control" rows="5" name="row[additional_information_on_drug_free_text]" cols="50">{$row.additional_information_on_drug_free_text}</textarea>
        </div>
    </div>

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">物质/指定物质标识符和规格:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar2" class="toolbar">
                <a href="javascript:;" data-number="2" data-title="物质/指定物质标识符和规格" data-href="/admin/presentationdrugcase/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 物质/指定物质标识符和规格</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table2" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">剂量信息:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar3" class="toolbar">
                <a href="javascript:;" data-number="3" data-title="剂量信息" data-href="/admin/presentationdrugdosage/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 剂量信息</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table3" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">病例中使用的适应症:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar4" class="toolbar">
                <a href="javascript:;" data-number="4" data-title="病例中使用的适应症" data-href="/admin/presentationdrugidentifier/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 病例中使用的适应症</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table4" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">药物反应/事件模型:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar5" class="toolbar">
                <a href="javascript:;" data-number="5" data-title="药物反应/事件模型" data-href="/admin/presentationdrugmatrix/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 药物反应/事件模型</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table5" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>


    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">药物对反应/事件的相关性评估:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar6" class="toolbar">
                <a href="javascript:;" data-number="6" data-title="药物对反应/事件的相关性评估" data-href="/admin/presentationdrugmatrixassessment/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 药物对反应/事件的相关性评估</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table6" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>


    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">药物的其他信息:</label>
        <div class="col-xs-12 col-sm-8">
            <div id="toolbar7" class="toolbar">
                <a href="javascript:;" data-number="7" data-title="药物的其他信息" data-href="/admin/presentationdrugother/add?cid={$row.id}"
                   class="btn btn-success infomaition" title="添加"><i class="fa fa-plus"></i> 药物的其他信息</a>
                <a href="javascript:;" class="btn btn-primary btn-refresh hide" title="{:__('Refresh')}" ><i class="fa fa-refresh"></i> </a>
            </div>
            <table id="table7" class="table table-striped table-bordered table-hover table-nowrap" width="100%">
            </table>
        </div>
    </div>





    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
